“I’m opposed to any expansion of Medicaid that doesn’t give Texas the flexibility that we want,” said Nelson, chairwoman of the Senate Health and Human Services Committee.

She remains a fierce critic of federal health care reform. “But if we could design a program that we could live with, I would suggest we take it to the federal government and say, you know, consider this,” she said.

Florida asked for and received a waiver to run its program a little differently, meaning Texas could also likely negotiate an expansion.

What would Texas want out of those negotiations? It could be getting Medicaid money sent in a block grant that the state would use as it chooses. The federal government has so far not been interested in allowing that approach.

Nelson says block grants aren’t a requirement and that there are other ways Texas could tailor its expansion.

“Co-pays, for example, to make sure people have some skin in the game,” she said. “Making sure that our emergency rooms get unclogged. There are a lot of things.”

State Rep. Garnet Coleman, D-Houston, says he’s working with House colleagues to figure out a compromise.

He says co-pays could work, as long as the people in Medicaid now — the very poor, the elderly and children — don’t have to pay for a doctor’s visit in the future. But he points out that whatever program is offered to Washington will need to pass muster with Texas conservatives.

“It has to be put together in such a way that the majority of this Legislature is satisfied that there are enough conservative principles in the expansion so that they satisfy their constituents,” Coleman said.

Nelson isn’t overly optimistic that Washington would accept a tailored Texas plan, although she says it’s worth a shot. Though the Texas Legislature can write a bill accepting the Medicaid expansion and send it to Perry’s desk, doing anything without his blessing would make finding support more difficult.

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